Blood Transfusion A clinician’s reference

First Edition

Hospital Transfusion Committee Centro Hospitalar de Conde São Januário (CHCSJ)

SS, Macao

September 2005

Hospital Transfusion Committee Centro Hospitalar de Conde São Januário (CHCSJ)

SS, Macao

1

BLOOD TRANSFUSION

A clinician’s reference

S

Hospital Tranfsusion Committee CHCSJ

Heath Bureau, Macau

2

Index

Introduction ------------------------------------------------------------------------------------------- 4

Useful Contacts --------------------------------------------------------------------------------------- 4

Administration of Blood and Blood Components -------------------------------------------------5

Informed Consent--------------------------------------------------------------------------------------7

Guidelines of the Blood Component Transfusion ------------------------------------------------ 8

Massive Blood Transfusion ------------------------------------------------------------------------ 12

Obstetric Haemorrhage ----------------------------------------------------------------------------- 13

Neonatal Transfusion -------------------------------------------------------------------------------- 14

Leukodepleted Blood -------------------------------------------------------------------------------- 17

Irradiated Blood Components ---------------------------------------------------------------------- 18

Autologous Donation-------------------------------------------------------------------------------- 19

Flowchart for applying PABD --------------------------------------------------------------------- 20

Standard Surgical Blood Order Schedule (SSBOS) --------------------------------------------- 21

Standard Blood Ordering Schedules

General and Vascular Surgery ----------------------------------------------------------------- 22

Cardiac and Thoracic Surgery ----------------------------------------------------------------- 23

Plastic Surgery ----------------------------------------------------------------------------------- 24

Neurosurgery ------------------------------------------------------------------------------------ 25

Otorhinolaryingology --------------------------------------------------------------------------- 26

Orthopedic Surgery ----------------------------------------------------------------------------- 26

Urology ------------------------------------------------------------------------------------------- 27

Obstetrics-Gynecology ------------------------------------------------------------------------- 27

Transfusion Reactions ------------------------------------------------------------------------------- 28

References -------------------------------------------------------------------------------------------- 31

3

FOREWORD The Hospital Transfusion Committee of Centro Hospitalar de Conde São Januário (CHCSJ) was

formed in 2004 to promote the concept of safe transfusion. The chairman of the committee is the

Director of CHCSJ. Other members of the committee come from various departments in the

hospital and include members from the Macao Blood Transfusion Centre.

With the sole purpose in mind the Hospital Transfusion Committee has formulated and approved

these Transfusion Guidelines as a reference to clinicians in the CHCSJ. This is the first edition.

We envisioned that future editions will incorporate suggestions and recommendations from the

users of the guidelines.

The committee would like to acknowledge the effort of Dr. David T Lopes and Dr. Hui Ping in

formulating the guidelines since 1999.

Hospital Transfusion Committee , CHCSJ

July 2005

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INTRODUCTION Blood transfusion is an essential part of modern health care. Used correctly, it can save life and

improve health. However, as with any therapeutic intervention, it may result in acute or delayed

complications. In addition, it carries the risk of transmission of infectious agents, such as HIV,

hepatitis viruses, syphilis, etc. It is also expensive and uses a scarce human resource.

The risks associated with transfusion can only be decreased by close collaboration between the

blood transfusion service and clinicians in managing the components of the transfusion process

for which they are each responsible:

1. an adequate supply of safe blood and blood products

2. the effective clinical use of blood and blood products

Considering the lack of transfusion medicine in the medical school and the rapid advance of

this field since the last decade, we provide this booklet for serving as a convenient reference

for issues relating to the clinical use of blood.

USEFUL CONTACTS Hospital Blood Bank: 3903226, 3903219

Dr. David Lopes: 6807838

Blood Transfusion Centre: 752522

Dr. HUI Ping:

Office: 7914307

Emergency: 6892637

Laboratory Supervisor: Mr. Hoo Chai

Office: 752522/7914386

Hospital service Supervisor: Mr. Choi Sio Cheok

Office: 752522/7914361

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ADMINISTRATION OF BLOOD AND BLOOD

COMPONENTS I. Request Form

Transfusion request form must be completely fulfilled and clinical details must be

provided.

II. Filter

• All blood components must be administered through a transfusion standard filter (170-

micron) to remove blood clots and other debris.

• Changing of blood filter every 4 hours.

III. Timing All blood components which have been kept outside the blood bank should be

transfused to the patient as soon as possible.

IV. Blood Warming

Never warm the blood and blood products outside the blood bank. Warming blood only restricted to:

• Adult patients receiving rapid and multiple transfusions (rate >2000ml/hour).

• Children receiving large volumes (>15ml/kg/hour).

• Exchange transfusions in infants.

• Rapid infusion through central venous catheters.

V. Concomitant Use of Intravenous Solutions Only normal saline (0.9 % saline) may be administered with blood components.

VI. Monitors during and after transfusion In first 5 minutes of beginning transfusion and every 30 minutes during transfusion, CHECK:

S Blood pressure

S Pulse

S Temperature

Suspect the major acute transfusion reactions, when:

S A sudden rise in temperature > 10C

S Shortness of breath/chest pain

S Back pain/loin tenderness

S Profound hypotension

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VII. Ordering and issuing Red Cells/Whole Blood

• Routine transfusions should be requested at least 24 hours in advance during the

working hours.

• ±60 mins must be allowed for the grouping and crossmatch testing for emergency

order.

• Uncross-matched blood – can only be issued in an emergency. The blood bank staff

will only release uncross-matched blood after he/she has received a request from a

medical doctor, who has agreed to take responsibility for any ensuing complications.

Fresh Frozen Plasma (FFP)

l ± 45 mins should be allowed for the product to thaw before issuing.

l No cross-matched test needed, but an EDTA sample for blood grouping should be

sent if the blood group is unknown.

l ABO compatible FFP should be used.

l The thawed FFP cannot be refrozen.

l The thawed FFP infusion should be used without delay within 2 hours to avoid loss

of potency of coagulation factors.

Platelets

- Are only available after discussion with a Hematologist.

- Patient’s blood group should be known before the product can be issued and the same

ABO group as the patient should be used as far as possible.

- Should be transfused as soon as possible after reaching the ward.

Cryoprecipitate

• ±45 mins should be allowed for the product to thaw.

• Is available only after discussion with a hematologist.

• No cross-matched test needed, but an EDTA sample for blood group should be sent

if the blood group is unknown.

• ABO-compatible cryoprecipitate is not required.

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INFORMED CONSENT I. POLICY

CHCSJ requires documentation that patients who receive non-emergent

transfusions be informed of the procedures, alternatives, risks and benefits of blood

and blood products. The patients must be given an opportunity to ask questions and it

must be documented that they agree to receive the blood and blood products.

II. CURRENT RISKS, BENEFITS AND ALTERNATIVES TO TRANSFUSION

The CTS has created a patient information sheet ‘What you should know about blood transfusion’ to aid in the discussion of the risks, benefits and alternatives to transfusion.

III. MEDICAL EMERGENCIES AND TRANSFUSION INFORMED CONSENT

l Signed consent not absolutely required for emergency transfusion.

l Document emergent nature of problem and efforts to obtain consent in progress notes.

IV. PARTIES RESPONSIBLE FOR OBTAINING TRANSFUSION INFORMED CONSENT

l Ordering physician responsible for obtaining consent.

l Responsibility can be delegated, but the person obtaining the consent must be knowledgeable in the risks, benefits and alternatives to transfusion and must be conversant with clinical indications for transfusion and clinical consequences of refusal of permission to transfuse.

V. DURATION OF VALIDITY FOR INFORMED CONSENT

l Informed consent is valid for an entire named course of treatment.

l May span multiple admissions.

l Surgical patients typically consented once per admission.

l Consents should be renewed when there is a significant change in risk associated with the treatment.

VI. REFUSAL OF BLOOD TRANSFUSION

l We honor wishes of patients who refuse transfusion.

l Refusal Transfusion Consent should be obtained and must be documented in medical record.

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GUIDELINES OF THE BLOOD COMPONENT

TRANSFUSION The following guidelines have been generally accepted by the well-recognized specialists in the

world.

I. RED BLOOD CELLS General guidelines

• Hb and Hematocrit:

There is no an absolute acceptable level for all patients exists. But the concept of,

transfusion is only indicated when Hb <7 g/dl, has been general accepted in most of the

countries in the world.

• Clinical data:

Clinical data like age, function of the end organs, sepsis, causes of anemia etc, should be

evaluated first at all.

• Acute blood loss:

Blood transfusion is indicated when adequate fluid resuscitation has failed to:

a) correct intravascular volume depletion

b) relieve symptoms

c) stabilize vital signs

• Chronic blood loss:

Blood transfusion is only indicated to relieve symptoms when appropriate medical

measures to improve red cell mass have been inadequate.

• Patient under anesthesia:

Blood transfusion should be based upon stability of vital signs.

Indications - Acute blood loss (> 1000ml within few hours) ± symptoms of hypovolemic shock

- Per ioperative with intra-operative blood loss > 750ml

- Perioperative with Hb < 8g / dl

- Iron deficiency and megaloblastic anemia:

Never transfuse, unless:

a Fail to response to pharmacologic therapy like Iron, B12 or Folate

b Severe decompensate symptoms, like tachycardia, dyspnea, severe dizziness, etc.

c Hb < 5g /dl

Volume: 250ml / unit

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Important to remember • The only true indication for the blood transfusion is the need to improve the delivery

of O2 to the tissues within a short time.

• Patients with anaemia of undiagnosed cause should not be transfused until appropriate

investigations have been performed.

• Routine or programmed transfusions should be requested at least 24 hours in advance

during the working hours.

II. WHOLE BLOOD

Whole blood is the complete collection of a single donation of blood, which contains

1. red cells

2. antigenic granulocytes

3. platelets without function

4. all the plasma proteins, but as a result of storage there is loss of activity by the

coagulant factors V and VIII:C and by complement.

Volume: 350ml/unit

Indication: Autologous transfusion only.

III. PLATELET

Preparation of platelets 1. Platelets concentrates:

Prepared from individual units of whole blood by centrifugation.

Each bag volume ≈ 50-60 ml, platelet count: 5.5×1010

An adult therapeutic dose = 4 single bags

2. Apheresis platelets:

Collected from an individual donor during 2-3 hours apheresis procedure.

Volume: 200-300ml/unit

Platelet count: 3×1011

Shelf life and Storage

5 days’ shelf life, at 22 ±20C, under constant and gentle agitation in a special incubator.

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Indications

The decision to transfuse platelets should not be based on low platelet count alone.

1. DIC with active bleeding (platetlet count < 20,000/ul) .

2. Severe thrombocytopenia (<10,000/ul) following chemotherapy.

3. Active bleeding with severe thrombocytopenia (platetlet count < 10,000/ul).

4. Thrombocytopenia, with scheduled invasive procedure.

5. Thrombocytopathy, bleeding time > 2 × normal with bleeding or scheduled

invasive procedure.

Platelets should not be transfused 1. Immune thrombocytopenia.

2. Prophylactically in most patients with aplastic anemia.

3. Thrombotic thrombocytopenic purpura/Hemolytic uraemic syndrome or

eclampsia.

IV FRESH FROZEN PLASMA Containing all clotting factors, but factor V and VIII is minimal.

Volume of each unit: 200 ml

Dose

Generally accepted starting dose: 2 units (10ml/Kg for coagulation factor replacement)

Indications 1. Definite indications:

• Replacement of single coagulation factor deficiencies, where a specific or combined factor

concentrate is unavailable.

• Immediate reversal of Warfarin

• DIC- acute disseminated intravascular coagulation

• Thrombotic thrombocytopenic purpura / Hemolytic ureamic syndrome

2. Conditional use:

Only indicated in the presence of bleeding and disturbed coagulation:

• Massive transfusion

• Liver disease

• Cardiopulmonary bypass surgery

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FFP should not be transfused

• For volume expansion

• A nutritional supplement

• Prophylactically with massive blood transfusion

• Prophylactically following cardiopulmonary

V. CRYOPRECIPITATE

Contains

• Factor VIII : 80-100iu/unit

• Fibrinogen :150-300 mg/unit

• Factor XIII

• Fibronectin

Volume of each unit: 10 ml

Dose: 10 individual units is a standard adult dose.

Indications

• DIC with active bleeding or before invasive procedure and APTT > 1.5× normal

• Hypofibrinogenemia (<100mg/dl) or dysfibrinogenemia with active bleeding or before

scheduled invasive procedure.

• Uremic thrombocytopathy unresponsive to DDAVP, with active bleeding or before

scheduled invasive procedure.

• Von-willebrand’s disease unresponsive to DDAVP with active bleeding or before

scheduled invasive procedure.

• Factor XIII deficiency

• As fibrin glue

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TRANSFUSION PRACTICE

I. MASSIVE BLOOD TRANSFUSION

Definition Massive transfusion is defined as the replacement of one or more blood volumes within 24

hours (≈ 4500ml in 60-kg adult).

Management - Minimum laboratory investigation in patients with acute hypovolaemic shock:

• Pre-transfusion testing (10ml clotted blood): - ABO, Rh grouping

- Crossmatch testing

• Hematology (2ml in EDTA): Full blood count.

• Coagulation (5ml in citrate): PT, APTT, Fibrinogen

• Biochemistry: baseline urea and electrolyte concentration

- Priorities in massive transfusion:

1) Replace and maintain blood volume

Initially, crystalloid or colloid solutions may give for restoring the blood volume.

Whole blood (first 4 units) should be followed while the compatible or suitable blood

has been prepared by the blood bank.

2) Maintain haemostasis

Stored citrate blood:

� clotting factors, mainly factor V and VIII loss activity

� platelets in stored blood have no function at all after 48 hours

storage.

When:

S platelet counts < 50×109/l, transfuse platelet

S either PT or aPTT are prolonged to > 1.8 × the control value, fresh frozen

plasma should be given (at least 4 units)

S fibrinogen < 100mg/dl, cryoprecipitate is indicated.

S Further, should be monitor by clinical response and laboratory test.

3) Optimise oxygen carrying capacity

S Maintain packed cell volume > 0.20 ( ≈ 6.0 g/dl )

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S The 2, 3-DPG level in stored blood cells reduced significantly for up to 14 days

after collection. It might be important for patients with pre-existing cardiac disease

or severe anaemia to have blood that is less than 14 days old.

4) Correct or avoid metabolic disturbances

The stored blood is :

S Hypocalcemia

S Hyperkalemia

S Acidosis

S Hypothermia

- Hypocalcaemia and hyperkalemia combinate with hypothermia cause by rapid

transfusion of blood stored at 4 0C, can cause cardiac irregularities – ECG

monitoring is advisable.

- Prophylactically calcium supplement is not recommended.

- The correction of acidosis by alkalising agent should be provided only by the

results of laboratory tests and not by the number of units of blood transfused.

- Warming blood by blood warmers.

5) Maintain plasma colloid osmotic pressure

Large volume of crystalloids and red cell preparation devoid of plasma for

replacement of blood loss will lead to a fall in plasma colloid osmotic pressure.

II. OBSTETRIC HAEMORRHAGE Obstetric haemorrhage caused 12 out of the 134 direct maternal deaths in the UK

annually. The blood flow to the placenta is 70 ml/min at term, so bleeding is likely to be rapid.

It is often unexpected and difficult to control. Disseminated intravascular coagulation is

common in obstetric haemorrhage due to placental abruption, amniotic fluid embolism and

intrauterine death.

Haemorrhage due to obstetric DIC is usually relieved only by treating the underlying

disorder, which usually involves rapid delivery. Supportive treatment with platelets, FFP and

cryoprecipitate may be required and should be guided by laboratory tests. Bleeding into the

uterine cavity, the uterine wall or the abdomen may conceal the extent of the blood loss. As a

result, the patient may decompensate suddenly in the post-delivery period.

The following management protocol is for reference:

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Transfusion in obstetric haemorrhage l Insert at least two large cannulas. Start saline infusion. Apply compression cuff to

infusion pack. Monitor central venous pressure (CVP) and arterial pressure. Take

samples for transfusion and coagulation screen. Order at least 6 units of red cells. Do

not insist on crossmatched blood if transfusion is urgently needed.

l Warm the resuscitation fluids.

l Transfuse red cells as soon as possible. Until then:

- crystalloid, maximum of 2 litres

- colloid, maximum of 1.5 litres

l Restore normovolaemia as priority, monitor red cell replacement with haematocrit or

Hb.

l Use coagulation screens to guide and monitor use of blood components.

l If massive bleeding continues, give FFP 1 litre, cryoprecipitate 10 units while awaiting

coagulation results.

l Monitor pulse rate, blood pressure, CVP, blood gases, acid-base status and urinary

output (catheterised).

III. NEONATAL TRANSFUSION A RED CELL

1. Characteristics of newborn infants

• Small size

• Physiologic anemia

• Iatrogenic blood loss

• O2 affinity of fetal hemoglobin

• Immature immune system

• Presence of maternal alloantibodies

• Variations in blood volume with age

• Shortened red cell survival

• Decreased erythropoiesis

• Cardiovascular adaptive capacity

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2. Indications for red cell transfusion to neonates and premature infants

• Shock associated with acute blood loss.

• Hb<13g/dl, Hct < 40% and pulmonary failure, cyanotic heart disease, or congestive

heart failure.

• Cumulative loss of 10% or more of the blood volume ≤ 72h if additional sampling is

required.

• Hb< 8g/dl or Hct < 25% in a stable neonate with clinical manifestations of anemia,

namely tachycardia, tachypnea, and poor feeding.

3. Pre Transfusion Testing

• ABO and Rh group of both mother and neonate

• DAT (Directed agglutinative test) of neonate

• Maternal blood for cross-match testing

4. Dose

Transfuse 3ml/kg packed red cell raise hemoglobin by 1g/dl.

B NON-RED CELL COMPONENT Platelet:

• DIC secondary to severe sepsis

• Dose: 5-10 ml / kg raise platelet count 75 to 100×109/l

Plasma and cryoprecipitates

FFP and Cryoprecipitate may be required in DIC and consumptive states (see section IV

and V), and therapy should be guided by the results of laboratory coagulation tests.

C MAIN TRANSFUSION SIDE EFFECTS IN NEONATE

• Hypocalcaemia

• Citrate toxicity

• Rebound hypoglycemia

• Virus infection

• Transfusional overload

• Hemolytic transfusion reactions in necrotising enterocolitis

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D Component volumes to be transfused to children and neonates.

1. Red cell concentrates A. Exchange transfusion

Volume: For a term infant: 80-160 ml/kg

For a preterm infant: 100-200 ml/kg

B. Top-up transfusion Desired Hb (g/dl) actual Hb weight (kg) 3 (usually 10-20 ml/kg)

2. Platelet concentrates Children weighing <15 kg: 10-20 ml/kg

Children weighing >15 kg: standard dose

3. Fresh frozen plasma: 10-20 ml/kg

4. Cryoprecipitate: 5 ml/kg or 15-30 kg = 5 units, >30 kg = 10 units

E Suggested transfusion thresholds for infants under 4 months of age

1. Transfusion of red blood cells

Anaemia in the first 24 h Hb 12 g/dl (Hct: 0.36) Cumulative blood loss in 1 week, neonate requiring

intensive care 10% blood volume

Neonate receiving intensive care Hb 12 g/dl

Acute blood loss 10% blood volume

Chronic oxygen dependency Hb 11 g/dl

Late anaemia, stable patient Hb 7 g/dl

2. Transfusion of platelets

Preterm or term neonate, with bleeding 50 109/l

Sick preterm or term infant, not bleeding 30 109/l

Stable preterm or term infant, not bleeding 20 109/l

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SPECIAL REQIREMENTS I. LEUKODEPLETED BLOOD

Cellular blood components that contain less than 5x10 6 leukocytes (white blood cells) are

considered leukocyte depleted. The leukocyte content of blood components can be reduced to

less than 5x106 by filtration. Cryoprecipitate and fresh frozen plasma do not contain intact or

viable leukocytes making leukodepletion unnecessary.

Indications

Leukodepleted blood and components are indicated:

• for patients who have experienced two or more non-hemolytic febrile transfusion reactions

• as a method of preventing transfusion transmitted CMV

• as a method of preventing platelet alloimmunization in certain patients

The purpose of transfusing leukocyte-depleted blood products is to:

n Reduce HLA alloimmunization to leukocytes in multiply-transfused patients

n Reduce the risk of cytomegalovirus transmission

n Decrease febrile transfusion reactions

n Other theoretical benefits remain speculative at this time

II. IRRADIATED BLOOD COMPONENTS

Irradiated blood products are exposed to approximately 2500 rads of Gamma radiation

to destroy the lymphocyte ’s ability to divide. Transfusion-associated graft-versus-host

disease (TA-GVHD) has not been reported from transfusion of cryoprecipitate or fresh

frozen plasma (FFP), thus these components do not require irradiation. Fresh plasma

(never frozen) for transfusion should be irradiated if the patient is at risk for TA-GVHD.

Indications

Absolute Indication:

• bone marrow transplant (BMT) recipients (allogeneic, autologous)

• BMT or stem cell donors if allogeneic transfusion must be given prior to completing the harvest

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• Cellular (T-cell) Immune Deficiency (congenital or acquired)

• intrauterine transfusion

• transfusions from family members (any degree)

• directed donors (when not identified as family members versus friends)

• HLA-matched platelet transfusions

Appropriate Indication:

• hematologic malignancies (leukemias)

• Hodgkin’s Disease

• non-Hodgkin’s Lymphoma

• neonatal exchange transfusion

• premature infants

• certain solid tumors (neuroblastoma, glioblastoma)

Therapeutic Effect

Irradiation destroys the ability of transfused lymphocytes to respond to host foreign

antigens thereby preventing graft vs. host disease in susceptible recipients. Patients with

functional immune systems will destroy foreign lymphocytes, making irradiation of blood

and blood components unnecessary.

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III. AUTOLOGOUS DONATION

Preoperative autologous blood donation

Some patients can donate their own blood - up to 4 units in advance of their own planned

operation. It can be stored for up to 5 weeks using standard hospital blood bank conditions. It

must be tested, processed, labelled and stored to the same standard as donor blood. Before re-

transfusion, autologous blood units must be ABO and Rh D grouped and compatibility

checked.

- Preoperative donations are made at CTS two to five weeks before operation.

- Service available on prescription basis.

- Autologous donation does not guarantee patient will not need additional banked blood.

- Autologous donation can make donor anemic and can increase chance of getting banked blood.

- Autologous blood is subject to same risks of clerical error and bacterial contamination that affect banked blood.

- Donation must be scheduled at CTS. Contact the physicians at CTS at 7914337 or 752522.

- Appropriate forms is available from the physicians in CTS or print from the homepage

of CTS http://www.ssm.gov.mo/cts/.

Patients suitable to predonate their own blood for surgery

• Operation scheduled is likely to need red cell transfusion.

• Date for surgery fixed, so the blood does not become outdated.

• Patient able to attend to have blood collected.

• Patient''s initial haemoglobin >100g/l (female) >110g/l (male).

• Sufficient time before surgery to donate at least 2 units of blood.

• Iron replacement is required during autologous donations.

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Procedure should be restricted to:

• Patients aged under 70 years

• Operations with a high blood loss

Not currently recommended in

Cardiac surgery patients (risk of thrombosis has not been excluded totally).

Flowchart for applying PABD

.

Patient visits Blood Transfusion Centre with the PABD Referral letter and ID card. (CTS-F8DS)

Meet the CTS’s physician

- Arrange collection dates - Give Iron Registration

Check BP, Weight & Hb

Pre-donation Screening

Unacceptable

Blood Collection

CTS physician will inform the clinician.

Blood Collection

Acceptable

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STANDARD SURGICAL BLOOD ORDER SCHEDULE (SSBOS) Purpose

When using the SSBOS, the Hospital Blood Bank will initially provide no more than the

designated amount of Red Blood Cells, although orders for fewer units will be followed. If

transfusion is not anticipated but may still occur, the maximum order is a “type and

screen.”

Specimens should be submitted at least one day before surgery. Specimens for pre-

transfusion testing can be collected up to 21 days prior to surgery when the patient has not

been pregnant or transfused in the past 3 months, otherwise the specimen can be collected

no more than 3 days before scheduled surgery.

Procedure

Adhere to the following guidelines:

T&C = Type and Cross.

T&S = Group/Type and antibody Screen.

NBR = No blood Required

NOTE: All the above orders and specimens are maintained in hospital blood bank for 7 days.

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STANDARD BLOOD ORDERING SCHEDULES GENERAL AND VASCULAR SURGERY

Amputation of limb A/K B/K

2 units T&S

Hematoma Evacuation T&S

Aneurysm, abdominal Aortic

Repair - elective Repair - emergent

4 units 6 units

Hemorrhoidectomy No blood Required

Appendectomy No blood Required

Hepatectomy 6 units

Angiography T&S Hernia repair,

Angioplasty T&S Ventral Other types

T&S NBR

Breast NBR Hodgkin’s or Lymphoma staging T&S

Augmentation/Reduction Biopsy

NBR NBR

Laparotomy, exploratory T&S

Mastectomy, simple or modified

NBR Liver biopsy T&S

Mastectomy, radical T&S Lymph node dissection T&S

Reconstruction T&S Pancreatectomy, partial or radical

3 units

TRAM 2 units Parathyroidectomy NBR

Bile Duct Exploration T&S Parotidectomy NBR

Bypass, vascular Porto/mesocaval, splenorenal shunt (portal hypertension)

6 units

Aorto-iliac, aorto-femoral, aorto-renal, axillary-femoral

2 units Pilonidal cyst or sinus resection

NBR

Carotid, Femoral-popliteal, Femoral-Femoral, iliac-femoral, iliac-popliteal

T&S Rectal Fistula NBR

Carotid endarterectomy T&S

Cholecystectomy, +/- CBDE T&S Skin Graft, split thickness T&S

Colectomy Splenectomy 2 units

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Subtotal T&S Sympathectomy T&S

Total or abdominal-perineal (AP)

2 units Thyroidectomy NBR

Colostomy, revision or closure

T&S Tracheostomy T&S

Embolectomy T&S Tumor resection, other T&S

Esophagectomy 3 units Ulcer repair, perforated

gastric T&S

Gastrectomy, subtotal or total, with or without vagotomy

2 units Vagotomy and pyloroplastyT&S

Gastroplasty, Mason (Gomez)

T&S Varicose vein stripping NBR

Gastrostomy T&S Vascular Access Procedures T&S

Hemangioma Resection T&S Wide excision, +/- skin graft T&S

CARDIAC AND THORACIC SURGERY

Aneurysm, thoracic, resection 4 units Lobectomy /pulmonary resection

2 units

Angioplasty, coronary T&S Lung Biopsy T&S

Atrial septal defect repair 2 units Pericardectomy /pericardiotomy

2 units

Arterial switch operation 4 units Pneumonectomy 2 units

Coarctation of aorta repair, Adult

3 units Tracheal reconstruction 4 units

Coronary bypass graft (CABG)

3 units Valve replacement 3 units

CABG Redo 3 units Ventricular septal defect repair

2 units

Esophagectomy 3 units Wolf-Parkinson White Procedure

3 units

Fontan Procedure 4 units Yag Laser Bronchoscopy 2 units

Hernia repair, all types, including primary & recurrent hiatal

T&S

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PLASTIC SURGERY

Orthognathic procedure with major osteotomy

T&S Otoplasty NBR

Cleft palate repair NBR Rhinoplasty NBR

Craniofacial procedure with intracranial component

2 units Skin flap T&S

Decubitus ulcer debridement/closure

T&S Wide Excisions, +/- skin graft

T&S

Mammoplasty Augmentation Reconstruction Reduction

NBR

NEUROSURGERY

Aneurysm, cranial 2 units Laminectomy, lumbar, for disk

NBR

Anterior cervical diskectomy, +/- fusion

T&S Laminectomy, cervical, thoracic or lumbar, for decompression

NBR

Carotid endarterectomy T&S Laminectomy, cervical, thoracic or lumbar, for tumor

2 units

Burr holes 2 units Lumbar or cervical fusion, posterior 2 units

Carpal tunnel release NBR Lumbar peritoneal shunt NBR

Cordotomy T&S Child T&S

Craniectomy for synostosis (child)

2 units Meningomyelocele repair T&S

Craniotomy Peripheral nerve exploration

T&S

For AV malformation 4 units Stereotactic brain biopsy NBR

For STA MCA or PICA bypass

T&S Syringoperitoneal shunt T&S

For intracranial hematoma

2 units Child T&S

For tumor T&S Subdural implants T&S

Hypophysectomy T&S Tarsal tunnel release NBR

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Lobectomy, Temporal or Cranial

T&S Ulnar nerve transposition NBR

Head Trauma 2 units Ventriculoatrial shunt NBR

Cranioplasty No blood

Required Ventriculoperitoneal

shunt NBR

OTORHINOLARYNGOLOGY

Acoustic tumor resection T&S Ma Masttoidectomy, partial or total

NBR

An Angiogiofibroma, resection

2 units Maxillectomy 2 units

Brachial cleft cyst, resection NBR Neurovascular reconstruction T&S

Caldwell-Luc procedure NBR Orb Orbital exploration T&S

Carotid body tumor resection 2 units Par Parotidectomy T&S

Craniofascial resection T&S Pharyngeal flap T&S

Cleft palate repair NBR Radical neck dissection T&S

Epistaxis T&S Retrolabyrinthine vestibular nerve resection

T&S

Ethmoidectomy NBR Rhinoplasty NBR

Glomus jugular tumor excision

2 units Temporal bone resection

T&S

Laryngectomy Simple T&S Tonsillectomy-adenoidectomy Post or with Bleeding

NBR

2 units

Laryngectomy with radical neck

T&S Tracheostomy NBR

Mandibulectomy, hemi or total 2 units

ORTHOPEDIC SURGERY

Amputation Fracture

Hemipelvectomy 4 units Acetabulum ORIF 2 units

Hip Disarticulation 3 units Closed, any NBR

BK (below Knee) T&S Hip, ORIF 2 units

AK (above knee) 2 units Hip, Hemiarthroplasty

2 units

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BE (forearm) T&S Humerus, ORIF 2 units

AE (above elbow T&S Radius, Ulna, Wrist NBR

Revision, any T&S Tibia, ORIF T&S

Arthroplasty Fusion

Hip, 1st operation 2 units Spine 1 or 2 levels 2 units

Hip, 2nd operation 4 units Spine 3 or more levels

4 units

Knee 2 units Spine Anterior and Post

4 units

Shoulder 2 units Shoulder 2 units

Arthrotomy Hip 3 units

Hip 2 units Other NBR

Other (Elbow, shoulder, Knee, etc

NBR Hand surgery NBR

Arthroscopy NBR Laminectomy, any T&S

Biopsy, femur, pelvis, humerus, or hip

T&S Meniscectomy NBR

Bone graft Pin Removal T&S

Pelvis, femur T&S Total Hip 2 units

Radius, Fibula, Tibia NBR

UROLOGY

Adrenalectomy 3 units ProProstatectomy

Cystectomy Partial Radical

T&S 4 units

Transurethral T&S

Cystolithotomy NBR Suprapubic 2 units

Cystoscopy NBR Perineal 2 units

Ileal loop T&S Radical 4 units

Fistual repair, ves.-vag or uret.-vag.

T&S Renal artery repair 3 units

Kidney biopsy, open T&S Retroperitoneal lymph node dissection

2 units

Lymph node dissection T&S Renal transplant T&S

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Meatotomy NBR TUR (Bladder Tumor) T&S

Nephrectomy, Simple T&S Ureterostomy T&S

Nephrectomy, Radical 4 units Urethral excision, implantation

T&C

Orchiectomy T&S Urethral procedure, other NBR

Penile implant T&S Vesicopexy (ALL) T&S

OBSTETRICS-GYNECOLOGY

Abortion, spontaneous, or termination during first or

second trimester NBR

Hysterectomy Any, except radical

Radical

T&S 2 units

Cervical conization NBR Laparoscopy T&S

Cesarean section Lymphadenectomy, Pelvic T&S

Uncomplicated T&S Oophorectomy or ovarian

wedge resection NBR

Known/suspected placenta previa 2 units Pelvic mass resection 2 units

Placenta percreta/accreta 3 units

After trial of forceps T&S Placenta previa under

observation T&S

With Hysterectomy 3 units Tubal ligation NBR Cesium implant NBR Tuboplasty NBR

Cystocele/Rectocele repair T&S Vaginectomy T&S

Deliveries, multiple (vaginal or abdominal)

T&S Vulvectomy, total or radical

2 units

Delivery accompanied by marked anemia (Hb <10 gms ) or shock

2 units

Ectopic pregnancy 2 units

Examination under anesthesia (EUA) for known/suspected placenta previa

2 units

High risk labor T&S

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TRANSFUSION REACTION I. ACUTE HEMOLYTIC TRANSFUSION REACTION

Cause: ABO-incompatible transfusion

Incidence: 1 in 25000 transfusions in the developed countries.

Signs/symptoms

S Fever, chills and general uneasiness

S Back pain, hemoglobinuria

S Dyspnea, hypotension, shock

S Uncontrollable bleeding, hemoglobinemia and anemia

Management

S Stop transfusion

S Keep iv patent with normal saline (0.9% N.S) 1000ml/hour Give Frusemid (250mg

by infusion over 4 hours)

S Dopamine, (infused at 3-5ug/kg/min)

The aim of all above is to achieve a urinary output of 0.5-1ml/kg/hour

S Check blood bag, label and patient identification

S Notify blood bank staff or hematologist

S Send back the transfused blood bag

S Take new blood samples of EDTA, clotted, citrate and urine from the patient to

blood bank

II. FEBRILE REACTION

Cause

1. Leucocyte antibodies in patients directed against donors leucocyte.

2. HLA antibody

Incidence: 0.5-1 in 100 transfusions

Signs/symptoms

The patient fell flushing in 5 minutes after beginning of the transfusion. Fell better soon

and has severe rigor and high temperature 60 minutes after the start of transfusion

( usually at the beginning of the second bag of the transfusion).

Treatment

Antipyretic medication like Paracetamol, etc.

29

III. ALLERGIC REACTION Cause

1. Allergy to transfused plasma protein?

2. Effect of cytokine?

Incidence: 1-2 in 100 transfusions

Signs: localized urticaria, erythema, and itching

Treatment:

Stop transfusion → antihistamine (Hydroxyzine, etc.) p.o or im → restart the transfusion

after symptoms have subsided (generally 15 – 30 minutes).

IV. BACTCTERIAL CONTAIMINATION

Mediators

Endotoxins produced by gram-negative bacteria

Signs/symptoms

Severe rigors, cardiovascular collapse, fever > 40 0C

Management

intravenous antibiotic; treat hypotension and DIC

V. DELAYED HEMOLYTIC TRANSFUSION REACTION (DHTR) Cause

Incompatible red cells are transfused and red cell alloantibody, usually, other than anti-A

and anti-B present in patient’s serum, like anti-D, anti-c, anti-Jka, anti K, etc.

Incidence: 1 in 1500 transfusions

Signs/symptoms

S 4 –7 days post-transfusion

S the patient with history of pregnancy or transfusion

S fever

S a fall of Hb or no reasonable rise of Hb after transfusion

S jaundice and hemoglobinuria

S progressive renal failure

Laboratory

S Spherocytosis in peripheral blood film

S DAT positive

S Antibody screening test positive

30

Management

S Daily urine output and renal function monitor

S Sent clotted blood sample to CTS for antibody identify

S Subsequent blood products transfused should be antigen negative for the patient ’s

corresponding antibody

VI. TRALI (TRANSFUSION-RELATED ACUTE LUNG INJURY) This is a severe , potentially fatal, transfusion reaction.

Cause: a leucocyte antibody in the donor ’s plasma specifically attack the recipient ’s lung

tissues to produce inflammation.

Incidence: 1 in 5000 transfusion in western countries.

Signs/symptoms: 1 – 6 hours post-transfusion:

S Chill and fever

S Non-productive cough, dyspnea

S Hypotension and marked hypoxaemia

Radiography

Characteristically perihilar and bilateral lower zone infiltration.

Differential diagnosis

1. Fluid overload

2. Cardiogenic pulmonary edema

Management

S Ensure enough fluid to avoid dehydration

S Oxygen therapy and respiratory support

S High-dose corticosteroids

VII. PTT (POST-TRANSFUSION THROMBOCYTOPENIA) Cause

Specific platelet antibodies in donor immune destruction of both patient’s and donor’s

platelets.

Signs/symptoms

5-12 days post-transfusion: sudden onset of severe thrombocytopenia.

Management: high dose intravenous immunoglobulin, 1-2g/kg for 3-5 consecutive days.

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VII. TR-GVHD (TRANSFUSION-RELATED GRAFT VS HOST DISEASE) Cause

Donor’s lymphoctes attack and destroy the recipient’s organs and tissues, such as liver,

bone marrow and gastrointestinal tract.

Incidence: 1 in 600 transfusions in Japan, rare in the other countries

Signs/symptoms

1-2 weeks post blood transfusion: - fever and diffuse erythematous rash

- diarrhea, bloody stool and liver dysfunction

- pancytopenia and marrow aplasia

- die

Mortality: very high

Management

S avoidance of ‘fresh blood’ transfusion

S avoidance of the transfusion from members of family

S gamma irradiation the blood cellular components

S chloroquine?

S Anti-CD3?

REFERENCES 1. Mollison, Engelfriet, Contreras, Blood transfusion in clinical medicine, 10th Edition

2. Marcela Contreras, ABC of Transfusion, 2nd edition

3. AABB, Blood Transfusion Therapy, 3rd edition

4. Jeanne A. L, etc, Current approaches to Red Cell Transfusion, Seminars in Hematology, Vol 33, no 4, 1996

5. Sally V. Rudmann, Blood Banking And Transfusion Medicine

6. Consensus statement on red cell transfusion, Transfusion Medicine, 1994. 4. 177-178

7. Guidelines for the use of fresh frozen plasma, Tansfusion Medicine, 1992, 2.57-63

8. Guidelines for administration of blood products: transfusion of infants and neonates, Transfusion Medicine,

1994, 4. 63-69

9. Developing a national policy and guidelines on the clinical use of blood – recommendations, Transfusion

Today, December 1998 ISSN: 1015-3276

10. C.Th., etc, Trigger Factors in Transfusion Medicine

11. Transfusion Manual May 2003, OHSU Transfusion Service U.S.A

12. Blood Components Reference Manual -- Pudget Sound Blood Center U.S.A

13. U.K Blood Transfusion Guidelines July 2003

Editors: Dr. HUI Ping Dr. David Lopes May 2005